Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that Jagir Singh, husband of the complainant, was the owner of Tata Ace vehicle bearing registration No.PB-04-AA-8843. He got his Vehicle comprehensively insured from the opposite party vide ‘Commercial Vehicle Package Policy’ no.36110031210300002717, which was valid from 11.10.2021 to 10.10.2022 and paid requisite premium of Rs. 20,900/- to the opposite party. The said premium included premium of Rs. 275/- towards personal accident insurance of owner-cum-driver i.e. Jagir Singh himself, to the tune of Rs. 15,00,000/- as sum assured and the personal accident coverage was also valid from 11.10.2021 to 10.10.2022. Further alleged that said Jagir Singh was in possession of a valid driving licence No.PB7620150002657, which was issued on 21.05.2021 and was valid upto 09.03.2027 for LMV, MCWG and the same was issued by Licensing Authority, Faridkot. During the subsistence of the above said insurance policy, said Sh. Jagir Singh met with an accident on 17.12.2021 near Dharamkot, Moga in the jurisdiction of PS Dharamkot, District Moga, when he was driving his Tata Ace and it struck against backside of a Truck. The insured vehicle was badly damaged. DDR No. 18 dated 30.12.2021 was recorded at P.S. Dharamkot, District Moga. Jagir Singh was taken to Moga Medicity Super Speciality Hospital, Moga and was got admitted there. During the hospitalization, he was operated upon and his spleen and intestine were removed and the cut end of the intestine was diverted to artificial opening in abdomen. The husband of the complainant was discharged from the said hospital on 26.12.2022. Due to removal of spleen and intestine, Jagir Singh was only able to take semi solid and soft diet and was unable to walk. He subsequently developed infection in his abdomen area and due to severe infection and post surgical complication he died on 21.01.2022 at his house. However, said Sh. Jagir Singh was not having any other history of illness. Further alleged that as the complainant and her family was not aware of the legal formalities and necessity of post mortem examination, so the complainant and her family performed the last rites of the deceased without getting conducted post mortem examination on the dead body of deceased. Thereafter the complainant being nominee in the policy immediately lodged the claim with Opposite Party. The Opposite Party was supplied with all the necessary documents including duly filed claim form. During the processing of the claim a letter dated 23.11.2022 was received by complainant from the Opposite Party sought reply from the complainant and demanded certain documents, which was duly replied by the complainant submitting detailed point wise reply vide letter dated 27.12.2022. However, vide letter dated 15.02.2023 the Opposite Party repudiated the claim of the complainant. The repudiation of the claim by the Opposite Party is arbitrary, illegal and unjustified and same amounts to deficiency in service on the part of the Opposite Party. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to pay an amount of Rs.15,00,000/- as claim amount.
b) To pay an amount of R.1,00,000/- as compensation for causing mental tension, harassment and agony to the complainant.
c) To pay an amount of Rs.50,000/- as litigation expenses and cost of complaint.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Party filed written version taking preliminary objections therein inter alia that this Commission has got no jurisdiction to try and decide the present complaint since there is no deficiency in service or negligence as alleged on the part of answering respondent. The complainant has lodged the claim in respect of death of her husband allegedly took place in accident. The complainant was called upon to submit the documents. The answering Opposite Party vide letter dated 23.11.2023 requested the complainant to submit the following necessary documents and reply to the following quarries:
i) Reason for delayed intimation to the personal accident loss to the company.
ii) Post-mortem report of the deceased
iii) FIR/DDR
iv) Inquest Report
v) Coroner's Report
vi) Driving Licence of deceased Jagir Singh
The complainant has duly received the said letter but even then she could not give proper reply and documents. After receipt of the reply of the complainant dated 27.11.2022, the claim file of the complainant was duly scrutinized by the competent authority of the Opposite Party and it was found that the claim of the complainant is not payable and the claim was repudiated vide registered letter dated 15.02.2023 and claim was repudiated on following grounds:
1. There is no post mortem report of the deceased Jagir Singh to prove that he had died due to injuries received in the alleged accident. There is no medical record to prove that death is due to injuries.
2 There is no coroner's report to prove the cause of death.
3. There is no inquest report.
4. As per contents of DDR no.18 dated 13.12.2021, the vehicle in question hit with a stray animal, but as per statements and survey report the vehicle in question hit behind the truck which was going ahead. So, there is misrepresentation of facts and false information has been provided while lodging the claim.
5. There is also delay intimation regarding personal accident claim which is also fatal and unexplained.
Further averred that he complainant has not provided above said documents and has also not proved that deceased died due to injuries received in the alleged accident. It is necessary to prove cause of death but the claimant has not proved cause of death in the present case. The complainant is not entitled for any relief. The complainant has not complied with the terms and conditions of the policy. As such the claim of the complainant is not payable as per terms and conditions of the policy and same has been rightly repudiated vide letter dated 15.02.2023; the present complainant is not maintainable since complicated question of law and facts are involved which required elaborated evidence both oral and documentary and as such it is only civil court of competent jurisdiction which can try and decide the present complaint. The complaint cannot be decided by this Honorable Commission in summary manner; the complainant is estopped by his own act and conduct from filing the present complaint since the complainant is not coming to the Commission with clean hands and had concealed the material facts from this Commission and as such she is not entitled to any discretionary relief from this Commission; the complainant has not impleaded all the legal heirs of deceased as part to the present complaint. On merits, it is submitted that the husband of the complainant has obtained insurance policy no.36110031210300002717 valid w.e.f 11.10.2021 to 10.10.2022 and the said policy was issued alongwith terms and conditions of the policy. Further averred that the said vehicle met with accident but nature of accident is not the same which has been disclosed by the complainant. It is submitted that as per contents of DDR no.18 dated 13.12.2021, the vehicle in question hit with a stray animal but as per statements, survey report and contents of the complaint, the vehicle in question hit behind the truck which was going ahead. So, there is misrepresentation of facts and false information has been provided while lodging the claim. Further averred that there is delay in lodging the claim and cause of death is also not due to injuries. There is no document on the file to prove that cause of death is injuries received in the accident. So, the claim has been rightly been repudiated. All other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, complainant has placed on record her affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C14.
4. Opposite Party placed on record affidavit of Smt.Sunita Mahajan, Sr. Divisional Manager, The New India Assurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1 to Ex.OP16.
5. We have heard the counsel for the parties and gone through the written arguments submitted on behalf of the complainant and also gone through the documents placed on record.
6. The case of the complainant is that her husband namely Jagir singh (now deceased) was the owner of Tata Ace Vehicle bearing registration no.PB-04-AA-8843 and he got his vehicle insured from Opposite Party for the period 11.10.2021 to 10.10.2022 During the policy coverage vehicle of the complainant’s husband met with an accident and husband of the complainant got injuries and got admitted in Moga Medicity Super Speciality Hospital, Moga and discharged from the hospital on 26.12.2022 and thereafter died on 21.01.2022 due to accidental injuries. Thereafter, she being nominee under the policy in question lodged the death claim of her husband with the Opposite Party, but they repudiated the claim.
7. Ld. counsel for the Opposite Party has repelled the aforesaid contentions on the ground that the death claim of the husband of the complainant repudiated on the grounds that there is no post mortem report of the deceased Jagir Singh to prove that he had died due to injuries received in the alleged accident. There is no medical record to prove that death is due to injuries; there is no coroner's report to prove the cause of death; there is no inquest report; as per contents of DDR no.18 dated 13.12.2021, the vehicle in question hit with a stray animal, but as per statements and survey report the vehicle in question hit behind the truck which was going ahead. So, there is misrepresentation of facts and false information has been provided while lodging the claim. Moreover, there is also delay intimation regarding personal accident claim which is also fatal and unexplained. Further averred that the complainant has not provided above said documents and has also not proved that deceased died due to injuries received in the alleged accident. As such the claim of the complainant is not payable as per terms and conditions of the policy.
8. We have perused the rival contentions of ld. counsel for the parties and gone through the record carefully. It is not disputed that husband of the complainant (now deceased) was the owner of Tata Ace Vehicle bearing registration no.PB-04-AA-8843 and he got his vehicle insured from Opposite Party for the period 11.10.2021 to 10.10.2022 During the policy coverage vehicle of the complainant met with an accident and husband of the complainant got injuries and got admitted in Moga Medicity Super Speciality Hospital, Moga and discharged from the hospital on 26.12.2022 and thereafter died on 21.01.2022. The grievance of the complainant is that the claim lodged by the complainant regarding death of his husband was repudiated by the Opposite Party. However, it has been contended by ld. counsel for the Opposite Party that death claim of the husband of the complainant was repudiated as there is no post mortem report of the husband of the complainant to prove that he had died due to injuries received in the alleged accident. There is no medical record to prove that death is due to injuries and there is contradiction in the DDR and as well surveyor report regarding the death of the insured and there was delay in intimation. On the other hand, ld. counsel for the complainant has vehemently contended that the husband of the complainant died due to an accidental injuries, which occurred on 17.12.2021 and as such was admitted immediately in Moga Medicity Super speciality Hospital, Moga. It is well evident from the copy of discharge summary on record Ex.C-5 and further the Medical Officer Moga Medicity Super Speciality Hospital has issued certificate Ex.C7, in which it has been clearly mentioned that the patient Jagir Singh was admitted in their Hospital on 17.12.2021 with alleged history of RSA (Road Side Accident) by clash of motor vehicle with truck. Patient presented in emergency with c/o severe pain in abdomen with tenderness and blunt trauma abdominal injury. In the circumstances as discussed, we feel that it is fully clear that the life assured died due to road side accident, as it is fully proved from the certificate Ex.C-7. The other contention of the learned counsel for the Opposite Party is that the claim has rightly been repudiated as the complainant did not submit the postmortem report and FIR about the accident in question, but we feel that the same are not fatal to the claim of the complainant and the claim of the complainant cannot be thrown on this ground alone. We are well guided by the judgement of Hon’ble State Consumer Disputes Redresal Commission, Punjab, Chandigarh in First Appeal No.323 of 2017, wherein the Hon’ble Punjab State Commission has also relied upon the pronouncement of National Commission in New India Insurance Company Limited Vs. State of Haryana and Ors. reported in 2008(2) CPJ 371 and 15, TPD Gram Sewa Sahakari Samiti Ltd. Vs. Charnjit Kaur reported in 2011 (4) CPJ 390 held as under:-
It is thus evident from perusal medical record of Sibia Healthcare Private Limited Sangrur that death of Buta Singh was on account of road side accident, having fallen from bicycle, which was a non-MLC case. As per the drift of law laid down by National Commission (supra), postmortem report and police report are not obligatory components before releasing the insurance claim by insurance company. Consequently, District Forum rightly appreciated the controversy in this case and awarded the claim amount to complainants being LRs of insured.
9. The other plea taken by the Opposite Party that there is delay intimation regarding personal accident claim which is also fatal and unexplained is also not genuine. However, as per the circular issued by the IRDA to the Insurance Companies that the genuine claim be not rejected on hyper technical grounds i.e. delay, which is reproduced as under:-
“INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY
Ref. IRDA/HLTH/MISC/CIR/216/09/2011 Dated:20.09.2011 CIRCULAR
To All life insurers and non-life insurers.
Re: Delay in claim intimation/documents submission with
respect to
i. All life insurance contracts and
ii. All Non-life individual and group insurance contracts.
The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.
The insurer’s decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.
Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.
The insurers are advised to incorporate additional wordings in the policy documents, suitable enunciating insurers’ stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured.
10. Furthermore, the repudiation the claim of the complainant made by the Opposite Party is not genuine, as the surveyor namely Piara Singh in his investigation report (Ex.OP9) duly mentioned that the claim is genuine, but the Opposite Party ignoring the report of the surveyor, demanded the documents from the complainant. The relevant para of the said report is reproduced as under:-
“Keeping in view the circumstantial and documentary evidences, it is established that accident to vehicle no.PB-04AA-8843 took place with another TP Truck Pb-13AF-8993 and claim is genuine. However, in the police report mention the wrong statement regarding the cause of loss (hit with animal) and presence of insured at police (while insured was not in position to visit the police station). In my opinion claim is genuine and subject to policy terms and conditions.”
Moreover, it has been settled by the Hon’ble Supreme Court of India that the report of the Surveyor cannot be brushed aside without valid reasons. In this context, reference may be made to the judgment of the Hon’ble Supreme Court reported as “Sri Venkateshwara Syndicate v. Oriental Insurance Company Limited, II (2010) CPJ 1 (SC)” in which it was held by the Hon’ble Supreme Court that the report of the Surveyor is to be given due importance and weight. Hon’ble National Commission in case cited as PRADEEP KUMAR SHARMA versus NATIONAL INSURANCE COMPANY, III(2008) CPJ 158 (NC), has been held that “Surveyor Report is an important document and cannot be brushed aside without any compelling evidence to the contrary”. Further in case New Horizon Sugar Mills Ltd. v. United India Insurance Co. Ltd. & Ors, 2003(3) CPR 136 (NC), the Hon’ble National Commission, New Delhi has observed that “report of Surveyor appointed under the provisions of Insurance Act has to be given greater importance.” In M/s Natain Cold Storage & Allied Industries Ltd. v . Oriental Insurance Co Ltd. 2003(3) CPR 114 (NC) it has been observed “surveyor’s report in the insurance claim is an important document which cannot be brushed aside easily.” Same view has been taken by the Hon’ble National Commission in case of Bhawana Kumar versus General Manager Varun Webres Ltd. & Anr, 2008(4) CPR 82 (NC). Not only this, recently Hon’ble National Consumer Disputes Redressal Commission, New Delhi in case National Insurance Company Limited Vs. M/s.Kiran Collector & Boutique 2019 (1) CLT 384 (NC), decided on 24th July, 2018 has held that “General rule is that the surveyors are appointed under the Insurance Act, 1938 and their reports are to be considered for settlement of insurance claims- The reports can not be brushed aside without any cogent reasons.” Hon’ble National Commission in the case of Ankur Surana v. United India Insurance Co. Ltd., reported in I (2013) CPJ 440 (NC), wherein it has been observed that "it is well established by now that the report of the surveyor is an important document and the same should not be rejected by the Fora below unless cogent reasons are recorded for doing so. The State Commission has stated that it did not see any legal ground before the District Forum to reject the report of the Surveyor. The report of the surveyor should have been rebutted on behalf of the complainant/petitioner since the respondents/OPs had filed the surveyor's report as their evidence."
From the discussion above, we are of the view that the Opposite Party-Insurance Company has wrongly and illegally rejected the claim of the complainant.
11. Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.15,00,000/- as sum assured with regard to the death claim of her husband. Perusal of policy document Ex.C2 shows that husband of the complainant was insured for Rs.15,00,000/-.
12. Sequel to the above discussion, the present complaint is partly allowed and Opposite Party is directed to pay an amount of Rs.15,00,000/- (Rupees Fifteen Lacs only) to the complainant as sum assured with regard to the death of her husband. Opposite Party is further directed to pay an amount of Rs.20,000/-(Rupees Twenty Thousand only) as compensation and Rs.10,000/- (Rupees Ten Thousand only) as litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, Opposite Party is further burdened with additional cost of Rs.25,000/-(Rupees Twenty Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
